Skilled nursing facilities are regulated by a layered system of federal and state agencies. At the federal level, the Centers for Medicare & Medicaid Services (CMS) sets the standards every facility must meet. At the state level, survey agencies conduct the actual inspections and issue licenses. Additional oversight comes from Long-Term Care Ombudsman programs, which investigate complaints and advocate for residents.
CMS Sets the Federal Standards
The Centers for Medicare & Medicaid Services is the primary federal regulator of skilled nursing facilities. Any facility that accepts Medicare or Medicaid payments must comply with CMS requirements known as “conditions of participation.” These cover nearly every aspect of care: staffing levels, infection control, resident assessments, nutrition, pharmacy services, and resident rights. CMS doesn’t just write the rules. It also certifies and recertifies facilities, determining whether they qualify to receive federal funding.
The foundation for today’s federal rules is the Nursing Home Reform Act, passed as part of the Omnibus Budget Reconciliation Act of 1987 (commonly called OBRA-87). That law transformed nursing home oversight by requiring standardized resident assessments, individualized care plans, and restrictions on the use of physical restraints and certain sedating medications. It also established the principle that facilities must help each resident achieve or maintain the “highest practicable” level of physical, mental, and psychosocial well-being.
CMS continues to update these requirements. In 2024, the agency finalized the first-ever federal minimum staffing standard for long-term care facilities: 3.48 hours of total nursing care per resident per day. That total must include at least 0.55 hours from a registered nurse and 2.45 hours from a nurse aide. Before this rule, there was no federal floor for how many staff a facility needed on any given shift.
State Agencies Conduct Inspections
While CMS writes the rules, state survey agencies do the on-the-ground enforcement. Under agreements authorized by Section 1864 of the Social Security Act, each state’s health department (or equivalent agency) sends inspectors into facilities to check compliance with federal standards. This process is called a “survey,” and it functions as the primary accountability mechanism for nursing homes across the country.
Federal law requires a standard survey of every skilled nursing facility no later than 15 months after its previous inspection. The statewide average interval between surveys must be 12 months or less, so while an individual facility might go slightly longer than a year between visits, the overall pace stays close to annual. Facilities with a history of poor performance, unresolved complaints, or reported incidents can be inspected more frequently, with no limit on how often a survey agency can return.
States also have their own licensing requirements that facilities must meet, which can go beyond the federal minimums. A facility could technically meet CMS standards but still face penalties from the state for violating state-specific rules. Both CMS and state governments can impose civil money penalties on facilities found out of compliance, including fines calculated on a per-day or per-incident basis.
How Facilities Are Rated Publicly
CMS publishes the results of this oversight through its Care Compare website, where every Medicare- and Medicaid-certified nursing home receives a rating on a one-to-five-star scale. The overall rating is built from three separate scores: health inspection results, staffing levels, and quality measures such as rates of falls, pressure ulcers, and emergency department visits. You can look up any certified facility and see its most recent inspection findings, staffing data, and how it compares to others in the same state.
The Ombudsman Program
Every state operates a Long-Term Care Ombudsman program, authorized under the Older Americans Act and coordinated by the Administration for Community Living. Ombudsmen are independent advocates for residents. They investigate complaints about health, safety, welfare, and rights in nursing homes, assisted living facilities, and other residential care settings. Unlike state survey agencies, which focus on whether a facility meets regulatory standards, ombudsmen focus on whether individual residents are being treated properly.
Ombudsman programs are required to identify, investigate, and resolve complaints made by or on behalf of residents. They also represent residents’ interests before government agencies, pursue administrative and legal remedies when needed, and recommend changes to laws and regulations. If a resident or family member has a concern that doesn’t rise to the level of a formal regulatory complaint, or if they’re unsure where to start, the ombudsman program is often the most accessible first contact.
How to File a Complaint
If you believe a skilled nursing facility is providing inadequate care or violating a resident’s rights, you can file a complaint with your state’s health department. Most states offer multiple ways to report: online forms, phone hotlines, fax, and mail. Many operate 24-hour complaint hotlines staffed seven days a week. Complaints can be filed by residents, family members, facility employees, or any member of the public.
Reportable concerns include suspected abuse, neglect, or exploitation. They also include criminal acts within a facility, deaths or injuries resulting from assaults, and fires or emergencies that cause harm or require evacuation. You don’t need proof to file a complaint. The state survey agency will investigate and determine whether violations occurred. If they find deficiencies, the facility must submit a plan of correction, and the agency may schedule a follow-up inspection to verify the problems have been fixed.
You can also contact your state’s Long-Term Care Ombudsman program, which can help you navigate the complaint process and advocate directly on a resident’s behalf. The Eldercare Locator (1-800-677-1116) can connect you with your local ombudsman if you’re not sure how to reach them.